LETTERS

TO

THE

nationwide,

EDITOR

multimodal

treatment

approaches.

A

major

3.

Henson cokinetic

therapeutic challenge is that of encouraging patients’ compliance with treatment efforts over time. This report describes a medication regimen, started in our New Orleans facility, that has been observed to afford both prompt relief of symptoms and sustained commitment to a multimodality team approach incorporating therapy,

psychotherapeutic and

family

Successive

groups,

individual

were

enrolled

in

the

cognitive-behavioral

psychotherapy,

crisis

and

intervention

medications

psychodynamic

counseling,

tailored

to

the

and

veterans’

psy-

follow-up.

Thirteen

men

required

brief

hospitaliza-

tion for acute exacerbation of PTSD, and 1 9 were lost to follow-up. Fifty-four men were found to have histories of drug and/or alcohol abuse, and 34 reported previous psychiatric hospitalizations.

clinicians sugsymptoms, including insomnia, nightmares of combat, and flashbacks. Simultaneously, patients began to attain therapeutic blood levels of antidepressant with low doses of tnicyclic and fluox-

gest

Patients’ reports verified separately 48-72-hour relief of persistent

etine,

without

the

unacceptable

by three hyperarousal

side

effects

of

higher

tnicyclic

doses ( 1-3). Treatment appeared to become effective against depressive symptoms within 3-8 weeks. Medications were monitored by the psychiatrist on a monthly basis for 6 months on average until a stable clinical situation prevailed. The cornbination of medications was well tolerated with few side effects, none of which was lasting. One patient developed a generalized skin rash after 30 days, and six men complained of erectile and ejaculatory delay but no true impotence. One veteran experienced a brief confusional state. Another patient, who had comorbid severe depression, PTSD, and alcoholism, attained the high blood level of 794 ng of amitriptyline after attempting

suicide

with

an

overdose.

toxification and survived raise important questions

without

He

was

referred

ill effect. These the need for careful

about

for

de-

problems medical

Carbamazepine, Disorder

dency toms ment

an opportunity to begin associated with extreme sense of hope of inadequate

situation.

their

and

Such

true

to address

frustrating

clinically

the psychological

sequelae

trauma. Importantly, the patient’s may be rekindled after many years

in therapy

gest the need for these medications mine

experiences

derived

double-blind, individually

in

conclusions, placebo-controlled and in combination

the

treatment

however,

sug-

studies of to deter-

efficacy.

REFERENCES I

.

2.

1270

(2)

Vaughan DA: Interaction of fluoxetine with tricyclic antidepressants (letter). Am J Psychiatry 1988; 145:1478 Schraml F, Benedetti G, Hoyle K, Clayton A: Fluoxetine and nortriptylinecombination therapy (letter). AmJ Psychiatry 1989; 146:1636-1637

M.D. PH.D. PH.D.

MADELINE KARIN

PH.D. PH.D.

alone

is effective

UDDO CRANE, E. THOMPSON,

in the

(1) and

acute

ofBipolar

Affective

in combination

and

prophylactic

La.

with

lith-

treatment

of

patients with bipolar affective disorder who have failed to respond to lithium. Although it has been suggested that patients with rapid cycling are more likely to respond to cambamazepine (1), careful attention has not been paid to the life course of illness of patients who respond to lithium, carbamazepine, and the combination of these two treatments. I therefore carried out a careful clinical evaluation of life course of illness in patients sequentially treated with lithium, carbamazepine, and the combination. Life course of illness was evaluated in 43 subjects with pnimany bipolar affective disorder followed in the Mood Disordens Program at the University of Toronto by a method previously described (3). Lithium was prescribed in doses of 900-1 800 mg/day to achieve blood levels of 0.7-1 .0 nmol/ liter. Carbamazepine was used in doses of 600-1600 mg/day, with therapeutic blood levels reached in all cases. Response to

a particular affective

treatment episode

was defined

for

which

and/or complete absence of 1 year. Since acute azepines

or

sessment

were

defined

cyclers

(four

ministered 22

were

some

to their

and

was

episodes involved cases,

this

life course

was

really

with

of illness

(persistent

no prolonged

as-

an

Patients

as rapid

in a 12-month

cyclers

depression

prescribed

for a minimum use of benzodi-

medication.

episodes

affective

of the acute

treatment

maintenance

and continuous

of normal

carbamazepine,

to

according

normal cyclers, between mania periods

in

response or more

as resolution

the

of affective treatment

neuroleptics

of

Twenty-five

the these adverse experiences, the observed tenfor prompt relief of chronic painful, debilitating sympby this combination of medicines may permit developof a more durable doctor-patient relationship as well as

ARTHUR P. BURDON, PATRICIA B. SUTKER, EDWARD F. FOULKS, M.D.,

and Life Course

Lithium,

SIR: Carbamazepine ium

monitoring. Despite

pharmaSumAsso-

New Orleans,

individual

needs. The psychotropic regimen consisted of an initial cornbination at bedtime of fluoxetine, 20 mg/day, with amitriptyline, SO mg, or an equivalent tnicyclic antidepressant and clonazepam, 0.5-1 mg. Eighty-six percent (N=136) of the men remained involved in group, individual, and family therapy at

6-month

Preskorn SH: Fluoxetine-TCA in CME Syllabus and Proceedings Meeting of the American Psychiatric DC, APA, 1990

psycho-

specialized PTSD clinic team program (N=158) were followed by the multidisciplinary treatment team for 12 months. All of the patients were free of psychosis and were free of drugs and alcohol for 30 days before treatment was initiated. Among the treatment

chotropic

mary, ciation.

JH,

therapies.

outpatients

modalities

SR, Beber interaction, 143rd Annual Washington,

period),

fluctuations on sustained

mood).

subjects

and

responded

seven

in sequential regular cyclers,

a continuous cycler. eight were rapid and

to lithium,

responded

1 1 responded

fashion. Of the 25 lithium two were rapid cyclers,

Of the

to

to the combination

1 1 carbamazepine

ad-

responders, and one was

responders,

three were regular cyclers. Of the seven who responded to the combination, two were regular and five were continuous cyclers. My careful clinical evaluation confirms earlier impressions that carbamazepine responders tend to have rapid cycling, whereas lithium responders have regular cycles of bipolar disorder. Of particular note was the finding that responders to combined lithium and carbamazepine were predominantly characterized by continuous mood cycles. This was not an attempt to carry out a controlled study but, rather, to provide

a careful

systematic

clinical

evaluation

of life course

of illness

in relation

to treatment response, subject to the limitations of the sequential treatment used. These observations are preliminary because of the clinical nature of the data collection and require clarification in a randomized, double-blind study of the acute and prophylactic efficacy of these treatments.

Am

J Psychiatry

1 48:9,

September

1991

LETTERS

REFERENCES I

2.

3.

.

Fawcett J, Kravitz HM: The long-term management of bipolar disorders with lithium, carbamazepine and antidepressants. J Clin Psychiatry 1985; 46:58-60 Nolen WA: Carbamazepine as a possible adjunct or alternative to lithium in bipolar disorder. Acta Psychiatr Scand 1983; 67:218-225 Roy-Byrne PP, Post RM, Uhde TW, Porcu T, Davis D: The Iongitudinal course of recurrent affective illness: life chart data from research patients at the NIMH. Acta Psychiatr Scand (Suppl) 1985; 317:1-34

RUSSELL T. JOFFE, M.D. Toronto, Ont., Canada

Cardiac

Transplantation

and

Depression

of surgical and anesthetic techniques, imselection of transplantation candidates, and the introof cyclosponine have resulted in a significant increase in both the number and survival of cardiac transplantation patients (1). A parallel rise has occurred in delayed postoperative psychiatric complications, particularly depression ( 1, 2). Treatment for these episodes typically involves psychotherapy and antidepressants, with occasional conjoint use of psychostimulants. However, a MEDLINE search of the literature revealed no reports on the use of ECT. I wish to report the successful treatment with ECf of a patient with a major depressive episode after cardiac transplantation. SIR:

Refinement

proved duction

Mr. A was a 6 1 -year-old white man who, 6 months after cardiac transplantation, presented with a breakthrough episode of DSM-IJI bipolar disorder, depressed type, while on a maintenance regimen of amoxapine, 150 mg nightly, and methylphenidate, S mg b.i.d. At admission his scone on the Hamilton Rating Scale for Depression was 34. He showed extreme anorexia and clinical deterioration. A reevaluation by the transplant team indicated stable graft function with life-threatening malnutrition and dehydration, which abrogated further medication trials. Following clinical stabilization of the patient, a decision was made to proceed with ECT. Before ECT, Mr. A was evaluated with a physical examination, a serum chemistry screen, urinalysis, an ECG with rhythm strip, chest X-ray, cranial Cf scan, a cervical and thoracic spine series, and sequential checks of vital signs. He received seven treatments of bilateral ECT administered with a Medcraft model B24-IH machine and standard ternporofrontal placement. Prestimulus preparation consisted of4O mg i.v. ofmethohexital, sphygnomanometnic isolation of the left upper extremity, SO mg i.v. of succinylcholine, and preoxygenation with 100% oxygen through a face mask, which was continued through posttmeatment necovery.

One

hundred

ten

volts

of pulse

wave

current

were

ap-

plied for 0.5 second per treatment, with the resultant tonicclonic seizure timed by monitoring of the left upper extremity. Cardiac status was monitored by a 12-lead ECG monitor, a pulse oximeter, and serial blood pressure measurements before treatment, immediately after seizure, and repeatedly until full recovery. Pretreatment blood pressure averaged 170/1 10 mm Hg; pulse, 96 bpm. Peak posttreatment blood pressure averaged 220/138 mm Hg; pulse, 130 bpm, responsive to S mg i.v. of labetalol after seizure. The patient experienced no other cardiac complications from ECT. Post-ED’ ECGs revealed no change from admission status.

Am

J

Psychiatry

148:9,

September

1991

TO

THE

EDITOR

Mr. A did experience post-ECT confusion characterized a decrease in his Mini-Mental State examination scone for 6 days following treatment S. His score decreased from 28 on admission to 19, with spontaneous recovery to a final scone of 28. His Hamilton depression scone improved to 9. He was discharged to follow-up on a regimen of amoxapine, 100 mg nightly. by

Although the vagal denervation resulting from cardiac transplantation obviates the risk of immediate postseizure bmadycamdia, clinical concern regarding the subsequent sympathetic discharge, with its attendant tachycardia and presson response (3), may have contributed to the dearth of reported cases of use of ECT in this special population. Despite the possibility of these and other cardiac complications, however, ECT has been well tolerated by other types of cardiac patients (3-5). This case indicates that ECT may be well tolerated in cardiac transplantation patients as well. Larger samples must be obtained to support further generalizations about the use of ECT in this population.

REFERENCES 1. Freeman AM, Folks DG, Sokol RS, Fahs JJ: Cardiac transplantation: clinical correlates of psychiatric outcome. Psychosomatics 1988; 29(1):47-54 2.

Watts

D, Freeman

of cardiac 3.

AM,

McGiffin

transplantation.

DG,

Heart

et al: Psychiatric

Transplantation

aspects

1984;

3(3):

243-247 Prudic

J, Sackeim HA, Decina P, Hopkins N, Ross FR, Malitz S: Acute effects of ECT on cardiovascular functioning: relations to patient and treatment variables. Acta Psychiatr Scand I 987; 75:344-351

4. Dec GW, Stern TA, Welch C: The effects of electroconvulsive therapy on serial electrocardiograms and serum cardiac enzyme values. JAMA 1985; 253:2525-2529 S. Mulgaokar GD, Dauchot PJ, Duffy P, Anton AH: Noninvasive assessment of electroconvulsive-induced changes in cardiac function. J Clin Psychiatry 1985; 46:479-482 EVERE1T

R. JONES,

JR.,

Houston,

Capgras’

Syndrome

in a Blind

M.D.

Tex.

Patient

SIR: Lately, most reports and articles about Capgnas’ syndrome have emphasized the importance of organic factors in its etiology, and many authors (1, 2) hypothesize that an al-

temation

in the visual routes of facial recognition role in it. We have seen a blind patient a delusion of doubles, in whom such an alteration to be an important etiopathogenic factor.

portant

plays an imwho suffered seemed not

Mn. A was a 32-year-old man who had a 12-year history of insulin-dependent diabetes mellitus. He had suffered a diabetic retinopathy and had been completely blind for 3 years. He had no psychiatric history. He was admitted to the hospital in a hypoglycemic coma and was treated with intravenous glucose. While recovering from the coma, he developed haptic and visual hallucinations of little animals and experienced temporospatial disorientation. An EEG showed signs of metabolic encephalopathy; a CT scan was normal. Treatment with halopenidol, S mg/day, was started, and in a week the hallucinations disappeared and consciousness was normal, but the patient began to express the conviction that a double had been substituted for his mother. At that time his mother was not at the hospital, and

1271

Carbamazepine, lithium, and life course of bipolar affective disorder.

LETTERS TO THE nationwide, EDITOR multimodal treatment approaches. A major 3. Henson cokinetic therapeutic challenge is that of encouragin...
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